5.2 Admission to post anesthesia care unit


Table 5:1 Components of a post anesthesia care unit admission report
Preoperative history
  • Medication allergies or reactions 
  • Pertinent earlier surgical procedures 
  • Underlying medical illness 
  • Chronic medications 
  • Acute problems (e.g., ischemia, dehydration)
  • Premedications
  • NPO status
Intraoperative factors
  • Surgical procedure 
  • Type of anesthetic
  • Relaxant/reversal status
  • Time and amount of opioids administered
  • Type and amount of intravenous fluids administered
  • Estimated blood loss
  • Urine output
  • Unexpected surgical or anesthetic events
  • Intraoperative vital sign ranges
  • Drugs given (e.g., steroids, diuretics, antibiotics, …)
Assessment and report of current status 
  • Airway patency 
  • Ventilatory adequacy 
  • Level of consciousness 
  • Level of pain
  • Heart rate and heart rhythm
  • Blood pressure 
  • Intravascular volume status
  • Size and location of intravenous catheters 
  • Overall impression
Postoperative instructions in collaboration with the surgeon.
  •  Expected airway and ventilatory status 
  • Acceptable vital sign ranges 
  • Acceptable urine output and blood loss
  • Surgical instructions (e.g., positioning, wound care) 
  • Anticipated cardiovascular problems
  • Orders for therapeutic interventions
  • Diagnostic tests to be secured
  • Therapeutic goals and end points before discharge
  • Location of responsible physician